Perception of gender norms and its association with bullying behavior among adolescent students.

BACKGROUND: Inequitable gender norms are increasingly seen as a risk to health and well-being. Although adolescence represents a critical phase of development before adulthood, there is limited understanding about adolescents' perception of gender norms in Egypt. Adolescents' nonconformity with stereotypical gender norms is suspected to increase their exposure to bullying behavior. This study aimed to explore the adolescents' perception of gender norms - especially towards romantic relations and stereotypical gender traits and roles - and its association with bullying behavior among school children. METHODS: A cross-sectional study of a sample of 400 students 11-17 years from 10 public schools in Aswan city, Egypt was conducted. Data were collected via interviewer-administered questionnaires using the Gender Norms Scales and School Life Survey tool for bullying. RESULTS: School adolescents of both sexes showed no significant difference with respect to their attitudes towards romantic relationships engagement, but boys were slightly more permissive about romantic relationships than girls (54.4%, 46.1%, respectively). On the other hand, girls were significantly more likely to indicate agreement with a sexual double standard regarding boy/girl relationships than boys (75% vs. 46.4%, P < 0.001). Regarding gender stereotypical traits, girls' and boys' perception showed no significant difference, but boys had more endorsement, and 64.3% of boys perceived more agreement with gender stereotypical traits compared to 57.4% of girls. Also, boys were more likely to express more agreement with stereotypical gender roles than girls (74% vs. 52.9%, P < 0.001). However, 51% of students agreed that it was okay to tease a boy who acted like a girl, and 27.5% agreed that it was okay to tease a girl who acted like a boy. Students' status of bullying and victimization was not significantly associated with any studied gender norms concept. CONCLUSIONS: Perception of unequal gender norms starts early in adolescence. Boys are more accepting of heteronormative relations among adolescents and more likely to endorse stereotypical gender roles than girls, while girls are more conservative and more likely to perceive a sexual double standard regarding boy/girl relationships. Moreover, adolescents of both genders perceived more agreement with deserving sanctions for atypical gender behaviors in boys with higher perception in boys compared to girls. However, both boys' and girls' perception of gender is not related to their status of bullying and victimization. This has important implications for understanding the development of gender norms and their impact on adolescent behavior and social interactions.

The effect of a maternal training programme on early childhood development in Egypt.

BACKGROUND: The initial years of life, particularly the first two years, are considered the most important for brain development and timely interventions profoundly affect the health of the child and families. AIMS: This study aimed to determine the effect of maternal health education on motor, social and cognitive development in infants less than two years old, and to identify the factors that could affect normal development. METHODS: Two hundred and ten mothers and their infants (109 interventions, 101 controls) were recruited from maternal and child health centres in Assiut Governorate, Egypt, in 2017. The maternal training programme has been taught to mothers of infants in intervention groups twice per month and up to five months' duration; however, routine services are provided to control groups only. Bivariate and multivariable analyses were performed to identify the most important predictors of normal development. RESULTS: There were significant improvements in early childhood developmental domains for the intervention groups after five months comparable to the base line assessment. Percent of normal development among intervention groups in communication subscale increased from 46.8% to 76% to 97.9% compared to 50.5% to 46.8% to 57.4% in the control groups (baseline, after two month and after five months assessment respectively). The intervention was a significant predictor in normal development. CONCLUSIONS: There was an improvement in early childhood developmental domains for the intervention groups after applying maternal training programme. Designing educational interventions for routine health care services that reach all children will provide mothers with the opportunity for improvement in early childhood developmental.

Health care providers' and mothers' perceptions about the medicalization of female genital mutilation or cutting in Egypt: a cross-sectional qualitative study.

BACKGROUND: Female genital mutilation/cutting (FGM/C) is a traditional harmful practice that has been prevalent in Egypt for many years. The medicalization of FGM/C has been increasing significantly in Egypt making it the country with the highest rate of medicalization. In this qualitative study, we explored the drivers and motives behind why healthcare professionals perform FGM/C and why mothers rely on them to perform the practice on their daughters. METHODS: The study drew on a "mystery client" approach, coupled with in-depth interviews (IDIs) and focus group discussions (FGDs) with health care providers (i.e. physicians and nurses) and mothers. It was conducted in three geographic areas in Egypt: Cairo, Assiut and Al Gharbeya. RESULTS: Study findings suggest that parents who seek medicalized cutting often do so to minimize health risks while conforming to social expectations. Thus, the factors that support FGM/C overlap with the factors that support medicalization. For many mothers and healthcare providers, adherence to community customs and traditions was the most important motive to practice FGM/C. Also, the social construction of girls' well-being and bodily beauty makes FGM/C a perceived necessity which lays the ground for stigmatization against uncut girls. Finally, the language around FGM/C is being reframed by many healthcare providers as a cosmetic surgery. Such reframing may be one way for providers to overcome the law against FGM/C and market the operation to the clients. CONCLUSION: These contradictions and contestations highlighted in this study among mothers and healthcare providers suggest that legal, moral and social norms that underpin FGM/C practice are not harmonized and would thus lead to a further rise in the medicalization of FGM/C. This also highlights the critical role that health providers can play in efforts to drive the abandonment of FGM/C in Egypt.

Measuring young adolescent perceptions of relationships: A vignette-based approach to exploring gender equality.

This paper reports the development and baseline data of a vignettes-based measure of gender equality. METHODS: Vignettes were developed through 3-day long focus groups. After piloting in 13 sites and repiloting a revised version in 6 countries, responses were categorized by the construct tapped and a scoring system developed. Finalized vignettes were then tested in DR Congo, Ecuador and China. RESULTS: Young adolescents can successfully respond to vignettes; and can differentiate self from hypothetical protagonists of same and opposite sex. Response differences by sex of respondent and protagonist were statistically significant across a range of scenarios and settings. CONCLUSION: This is the first vignettes-based measure for young adolescents assessing young adolescent perceptions of relationships differentiated by sex of the protagonist.

'Yeah, I've grown; I can't go out anymore': differences in perceived risks between girls and boys entering adolescence.

This analysis is based on data from the Global Early Adolescent Study, which aims to understand the factors that predispose young people aged 10-14 years to positive or negative health trajectories. Specifically, interview transcripts from 202 adolescents and 191 parents across six diverse urban sites (Baltimore, Ghent, Nairobi, Ile Ife, Assuit and Shanghai) were analysed to compare the perceived risks associated with entering adolescence and how these risks differed by gender. Findings reveal that in all sites except Ghent, both young people and their parents perceived that girls face greater risks related to their sexual and reproductive health, and because of their sexual development, were perceived to require more protection. In contrast, when boys grow up, they and their parents recognised that their independence broadened, and parents felt that boys were strong enough to protect themselves. This has negative consequences as well, as boys were perceived to be more prone to risks associated with street violence and peer pressure. These differences in perceptions of vulnerability and related mobility are markers of a gender system that separates young women and men's roles, responsibilities and behaviours in ways that widen gender power imbalance with lifelong social and health consequences for people of both sexes.

Exploration of Gender Norms and Socialization Among Early Adolescents: The Use of Qualitative Methods for the Global Early Adolescent Study.

PURPOSE: The Global Early Adolescent Study (GEAS) was launched in 2014 with the primary goal of understanding the factors in early adolescence that predispose young people to subsequent sexual risks, and conversely, those that promote healthy sexuality across different cultural contexts. The present article describes the methodology that was used for the first phase of GEAS, which consisted of conducting qualitative research to understand the gendered transitions into adolescence and the role that gender norms play within the key relationships of adolescents. Researchers from each of the sites that had completed data collection were also elicited for their feedback on the key strengths, challenges, and lessons learned from conducting research among 11- to 14-year-old adolescents. The purpose of this article is to present the description of each of the methods that were used in GEAS, as well as the researchers' perspectives of using the methods among early adolescents in their sites. METHODS: The GEAS is being implemented through a collaboration of university and nongovernmental institutions from 15 cities: Assiut (Egypt) Baltimore (U.S.), Blantyre (Malawi), Cape Town (South Africa), Cochabomba (Bolivia), Cuenca (Ecuador), Edinburgh (Scotland), Ghent (Belgium), Hanoi (Vietnam), Ile-Ife (Nigeria), Kinshasa (DRC), Nairobi (Kenya), New Delhi (India), Ouagadougou (Burkina Faso), and Shanghai (China). Approximately 30 in-depth interviews among adolescents and 30 in-depth interviews with their parent/guardian were conducted at each site, with adults and adolescents interviewed separately. To build trust and increase engagement among the adolescent participants, we used two different visual research methods: (1) timeline exercise which was small group based and (2) the Venn diagram exercise which was conducted individually and used at the start of the in-depth interview. RESULTS: The visual aspects of both the timeline and the Venn diagrams not only helped to produce data for the purposes of the study, but also were a successful way of engaging the adolescent participants across sites. While the narrative interviews produced extremely rich data, researchers did notice that there were a few challenges among the younger adolescents. Challenges were related to the length of the interview, comprehension of questions, as some of the questions were either too abstract or asked adolescents about an experience they had not yet had and therefore could not address or articulate. CONCLUSIONS: Conducting the first phase of GEAS revealed important insights for research with participants who are in this developmental phase of early adolescence. Methods that involve greater engagement and those that are visual were shown to work well irrespective of the cultural setting.

"A Boy Would Be Friends With Boys and a Girl With Girls": Gender Norms in Early Adolescent Friendships in Egypt and Belgium.

PURPOSE: A gender analysis was conducted to illuminate the key elements of friendships highlighted by early adolescent girls and boys in two sites for the purpose of better understanding the impact of gender norms on adolescent friendships in different contexts. METHODS: Narrative interviews with early adolescents were conducted in two sites: Assiut, Egypt (n = 37) and Ghent, Belgium (n = 30). The interviews were recorded, transcribed, translated into English, and coded using Atlas.ti for analysis. RESULTS: In both Assiut and Ghent, early adolescents reported some similarities in defining key characteristics of their same-sex friends as well as in the activities they share. However, differences were noticed among boys and girls within each site. In addition, the scope of shared activity was broader in Ghent than in Assiut. In both sites, few opposite-sex friendships were reported. Gender norms influenced choice of friends as well as the type and place of shared activities. CONCLUSIONS: Building on knowledge that adolescent friendships guide and reinforce attitudes, beliefs, and behaviors that impact immediate and long-term health, our findings indicate that gender norms inform early adolescent friendships, which may impact healthy development.

Cost-Effectiveness Analysis of Family Planning Services Offered by Mobile Clinics versus Static Clinics in Assiut, Egypt.

Cost effectiveness studies of family planning (FP) services are very valuable in providing evidence-based data for decision makers in Egypt. Cost data came from record reviews for all 15 mobile clinics and a matched set of 15 static clinics and interviews with staff members of the selected clinics at Assiut Governorate. Effectiveness measures included couple years of protection (CYPs) and FP visits. Incremental cost-effectiveness ratios (ICER) and sensitivity analyses were calculated. Mobile clinics cost more per facility, produced more CYPs but had fewer FP visits. Sensitivity analysis was done using: total costs, CYP and FP visits of mobile and static clinics and showed that variations in CYP of mobile and static clinics altered the ICER for CYP from $2 -$6. Mobile clinics with their high emphasis on IUDs offer a reasonable cost effectiveness of $4.46 per additional CYP compared to static clinics. The ability of mobile clinics to reach more vulnerable women and to offer more long acting methods might affect a policy decision between these options. Static clinics should consider whether emphasizing IUDs may make their services more cost-effective.

Cost-Effectiveness analysis of family planning services offered by mobile clinics versus static clinics in Assiut, Egypt

Cost effectiveness studies of family planning (FP) services are very valuable in providing evidence-based data for decision makers in Egypt. Cost data came from record reviews for all 15 mobile clinics and a matched set of 15 static clinics and interviews with staff members of the selected clinics at Assiut Governorate. Effectiveness measures included couple years of protection (CYPs) and FP visits. Incremental cost-effectiveness ratios (ICER) and sensitivity analyses were calculated. Mobile clinics cost more per facility, produced more CYPs but had fewer FP visits. Sensitivity analysis was done using: total costs, CYP and FP visits of mobile and static clinics and showed that variations in CYP of mobile and static clinics altered the ICER for CYP from $2 -$6. Mobile clinics with their high emphasis on IUDs offer a reasonable cost effectiveness of $4.46 per additional CYP compared to static clinics. The ability of mobile clinics to reach more vulnerable women and to offer more long acting methods might affect a policy decision between these options. Static clinics should consider whether emphasizing IUDs may make their services more cost-effective

Mobile clinics for women's and children's health.

BACKGROUND: The accessibility of health services is an important factor that affects the health outcomes of populations. A mobile clinic provides a wide range of services but in most countries the main focus is on health services for women and children. It is anticipated that improvement of the accessibility of health services via mobile clinics will improve women's and children's health. OBJECTIVES: To evaluate the impact of mobile clinic services on women's and children's health. SEARCH METHODS: For related systematic reviews, we searched the Database of Abstracts of Reviews of Effectiveness (DARE), CRD; Health Technology Assessment Database (HTA), CRD; NHS Economic Evaluation Database (NHS EED), CRD (searched 20 February 2014).For primary studies, we searched ISI Web of Science, for studies that have cited the included studies in this review (searched 18 January 2016); WHO ICTRP, and ClinicalTrials.gov (searched 23 May 2016); Cochrane Central Register of Controlled Trials (CENTRAL), part of The Cochrane Library. www.cochranelibrary.com (including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register) (searched 7 April 2015); MEDLINE, OvidSP (searched 7 April 2015); Embase, OvidSP (searched 7 April 2015); CINAHL, EbscoHost (searched 7 April 2015); Global Health, OvidSP (searched 8 April 2015); POPLINE, K4Health (searched 8 April 2015); Science Citation Index and Social Sciences Citation Index, ISI Web of Science (searched 8 April 2015); Global Health Library, WHO (searched 8 April 2015); PAHO, VHL (searched 8 April 2015); WHOLIS, WHO (searched 8 April 2015); LILACS, VHL (searched 9 April 2015). SELECTION CRITERIA: We included individual- and cluster-randomised controlled trials (RCTs) and non-RCTs. We included controlled before-and-after (CBA) studies provided they had at least two intervention sites and two control sites. Also, we included interrupted time series (ITS) studies if there was a clearly defined point in time when the intervention occurred and at least three data points before and three after the intervention. We defined the intervention of a mobile clinic as a clinic vehicle with a healthcare provider (with or without a nurse) and a driver that visited areas on a regular basis. The participants were women (18 years or older) and children (under the age of 18 years) in low-, middle-, and high-income countries. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the titles and abstracts of studies identified by the search strategy, extracted data from the included studies using a specially-designed data extraction form based on the Cochrane EPOC Group data collection checklist, and assessed full-text articles for eligibility. All authors performed analyses, 'Risk of bias' assessments, and assessed the quality of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS: Two cluster-RCTs met the inclusion criteria of this review. Both studies were conducted in the USA.One study tested whether offering onsite mobile mammography combined with health education was more effective at increasing breast cancer screening rates than offering health education only, including reminders to attend a static clinic for mammography. Women in the group offered mobile mammography and health education may be more likely to undergo mammography within three months of the intervention than those in the comparison group (55% versus 40%; odds ratio (OR) 1.83, 95% CI 1.22 to 2.74; low certainty evidence).A cost-effectiveness analysis of mammography at mobile versus static units found that the total cost per patient screened may be higher for mobile units than for static units. The incremental costs per patient screened for a mobile over a stationary unit were USD 61 and USD 45 for a mobile full digital unit and a mobile film unit respectively.The second study compared asthma outcomes for children aged two to six years who received asthma care from a mobile asthma clinic and children who received standard asthma care from the usual (static) primary provider. Children who receive asthma care from a mobile asthma clinic may experience little or no difference in symptom-free days, urgent care use and caregiver-reported medication use compared to children who receive care from their usual primary care provider. All of the evidence was of low certainty. AUTHORS' CONCLUSIONS: The paucity of evidence and the restricted range of contexts from which evidence is available make it difficult to draw conclusions on the impacts of mobile clinics on women's and children's health compared to static clinics. Further rigorous studies are needed in low-, middle-, and high-income countries to evaluate the impacts of mobile clinics on women's and children's health.

Gender-role attitudes among Egyptian adolescents.

Using nationally representative survey data, this study explores gender-role attitudes among unmarried adolescents aged 16-19 in Egypt, a society characterized by distinct and often segregated roles for men and women. Adolescents' views about desirable qualities in a spouse as well as more direct indicators of gender-role attitudes are examined, including opinions about whether wives should defer to their husbands, share in household decision making, and have the responsibility for performing domestic tasks. The findings regarding spousal characteristics reflect strong gender differentiation. Girls and boys provide divergent profiles of an ideal spouse, profiles that reflect traditional gender roles. Girls are significantly less likely than boys to favor educational inequality between spouses, however. Neither boys nor girls have egalitarian gender-role attitudes, although girls are significantly more likely to express less traditional attitudes. Multivariate analyses indicate that girls' and boys' attitudes do not vary consistently and significantly by socioeconomic background; in particular, increased schooling does not always promote egalitarian attitudes. The implications of these findings are discussed.

The decline of female circumcision in Egypt: evidence and interpretation.

Female circumcision is widespread in Egypt. Research suggests that the practice persists because of a belief that circumcision will moderate female sexuality, that it will assure a girl's marriagability, and that it is sanctioned by Islam. Using data from a nationally representative survey of adolescents, this paper investigates the prevalence and social correlates of circumcision among girls aged 10-19, the circumstances surrounding the procedure, and the attitudes of adolescents towards it. While the vast majority of adolescents are circumcised, a life table analysis indicates that girls today are at least 10 percentage points less likely to undergo female circumcision than were their mothers. Circumcision may have begun to decline prior to the time when the current cohort of girls were at risk; however, the data hint at a temporal association between the decline and the 1994 International Conference on Population and Development (ICPD) in Cairo, a time when the campaign against circumcision gained momentum. Over half of circumcised girls reported that the procedure was performed by a physician or nurse rather than a traditional practitioner. This represents a substantial increase over rates of "medicalized" circumcision found among earlier cohorts of Egyptian women. Even among circumcised girls, support for the practice is by no means universal, with 14 percent saying they think the procedure is unnecessary and a further 28 percent expressing ambivalence. A multivariate analysis indicates that girls who have been or are currently in school, who live in urban governorates, and who are older are more likely to believe that circumcision is not obligatory. When the analysis includes boys as well as uncircumcised girls, a large gender gap emerges, with boys considerably more supportive of the practice than are their female counterparts.